Trevor Summerfield was in his early 20s when his twin brother threatened to take his own life in front of him. Fortunately, he didn't follow through on the threat. Now, seven years later, Summerfield is the American Foundation for Suicide Prevention’s (AFSP) manager of federal policy; he makes sure every federal dollar spent on suicide prevention is used to the absolute fullest. “It’s fit into my life in a way that I didn’t anticipate,” he says.

Suicide is a unique problem in that it’s present pretty much everywhere — and isn’t going away. According to the World Health Organization, someone in the world dies of suicide every 40 seconds, adding up to approximately 800,000 people every year.

But our most publicized methods for preventing suicide have frustratingly mixed evidence behind them. For instance, a large 2009 review study found that public awareness campaigns only modestly improved acceptance of mental illness; the study couldn’t conclude whether these programs actually reduced rates of death by suicide. A 2010 study in the journal Crisis found that some public awareness campaigns may have actually deterred some adolescents from seeking help when they experienced suicidal thoughts.

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The biggest cause of suicide is a treatable, medical illness called depression.

Kelly Posner, PhD

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Part of the issue is that it’s hard to really study how effective things like the National Suicide Prevention Lifeline, a government-funded hotline, really are. We know that people who are suicidal and do call generally feel better after the call. But you can’t do a randomized, placebo-controlled trial of suicide hotlines like you might for an antidepressant, so we can’t really know if the existence of suicide hotlines prevents more suicides than not having one available at all.

The biggest problem, though, is that these, like so many other suicide prevention techniques, rely on the person with suicidal thoughts or behaviors to step forward. To do this, that person must confront deeply-ingrained cultural stigmas against both suicide and seeking help for mental health issues.

People who die by suicide are likely to have a few key things in common: Substance abuse, stressful life events (e.g. losing a job), and prior suicide attempts all rank in the top risk factors. And, most importantly, although the vast majority of people with mental illness don't die by suicide, it’s estimated that 90% of people who do die this way also deal with a mental illness.

“The biggest cause of suicide is a treatable, medical illness called depression,” says Kelly Posner, PhD, founder and director of the Center for Suicide Risk Assessment at Columbia University.

Photo: Martin Lee/REX Shutterstock. Illustrated by Elliot Salazar.

While working on a way of assessing the risk of suicide in adolescents, Dr. Posner realized that there wasn’t a single risk-assessment questionnaire that encapsulated both the thoughts and behaviors associated with suicide risk. So, she and her team pioneered the Columbia-Suicide Severity Rating Scale (C-SSRS), which captures an aspect of suicidal thoughts that most people don’t realize: Not all suicidal thoughts are the same.

Answering "yes" to the question “Have wished you were dead in the past month?” might seem like cause for alarm — and it is, to some extent — but saying "yes" to “Have you actually had any thoughts about killing yourself in the past month?” would indicate more immediate risk. So, someone who hopes to not wake up in the morning isn’t the same as someone who’s planning to jump in front of the A train during rush hour. And neither of those people are the same as someone who bought a gun yesterday.

Different kinds of suicidal thoughts merit different interventions, in Dr. Posner’s opinion. Automatically placing someone who has expressed any of these feelings on suicide watch in an ER might not be the most efficient use of resources and may actually dissuade people from reaching out if they think the reaction is going to be severe. Instead, thanks to this questionnaire, these extreme measures are saved for only those who would most benefit from them.

And, crucially, you don’t have to have any mental health training to administer the C-SSRS. So, Dr. Posner says, that means that EMTs can use the shorter version of the assessment to look out for suicide risk factors in their colleagues, bus drivers can watch for them in students, and you can be aware of them, too.

With this questionnaire, for the first time, everyone has a tool they can use to capture the full extent of suicide risk, making it harder for people to slip through the cracks.

The C-SSRS encapsulates one major arm of a large, government-funded suicide prevention effort, Zero Suicide. The project was founded in 2012 as part of the National Strategy for Suicide Prevention, with the idea that absolutely no one who regularly receives health care should die of suicide; those deaths are completely preventable. And because roughly half of people who die by suicide see their primary care doctor the month before their deaths, training those doctors to know what to look for is an obvious solution that could have a substantial impact.

“We should be asking [about suicide risk] like we monitor for blood pressure,” says Dr. Posner. “If we don’t ask everybody, we’re not going to find the people suffering in silence.”

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Photo: Mood Board/REX Shutterstock. Illustrated by Elliot Salazar.

Another key element of Zero Suicide is something called “safety planning.” This is a short intervention in which a therapist and a patient with suicidal thoughts can come up with a practical plan of clear, escalating steps to take in order to keep the patient safe. This includes being able to recognize the signs of an impending suicidal crisis, identifying your own coping strategies, and calling friends, family, and mental health professionals.

“One of the major turning points in the last couple decades has been thinking of suicide and suicidal behavior as not just part of depression,” says Barbara Stanley, PhD, director of Columbia University’s Suicide Prevention-Training, Implementation, and Evaluation Program and creator of the safety planning intervention. Although depression and suicide are clearly related, Dr. Stanley says looking at suicidality as “above and beyond depression” allowed researchers to develop very quick and specific intervention strategies like this one.

“As an organization, we’ve developed research and policy agendas to really inform evidence-based practices,” says the AFSP’s Summerfield, “and to make sure that all dollars that are spent on our cause are going to something we and professionals feel is going to help the issue.”

The AFSP regularly lobbies for more research dollars and then uses that research to inform what they lobby for in the future. For instance, the Model School Policy was created with the help of years of research into suicide risk factors and prevention in school-aged kids. The comprehensive policy suggests practical things, such as adding coping and help-seeking strategies to K-12 health classes, developing training programs for teachers and school counselors, and having a plan in place ahead of time to prevent “suicide contagion.”

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We should be asking [about suicide risk] like we monitor for blood pressure.

Kelly Posner, PhD

”

Embedded in all of these strategies — making it easier to reach out and more effective when we do — is the need to confront the stigma of suicide. If everything is telling us that suicide is “selfish” or “immoral,” we can’t expect people to come forward, and we can’t expect their friends to speak up. But, contrary to popular belief, mentioning suicide to someone doesn’t make that person more likely to pursue it. In fact, studies have shown that genuinely asking people about their suicidal thoughts — and taking them seriously — actually does make those people feel less distressed.

So, beyond everything else, we can’t be afraid to meet each other at least halfway. But companies are making that easier. For instance, earlier this year, Facebook implemented a feature through which we can alert the company that a friend may be in trouble. The site will then privately reach out to that person with ways to get help. And therapy is taking new forms that make it seem more approachable: Joyable for those with social anxiety, Panoply for people with depression, and 7 Cups of Tea for a chance to chat about pretty much anything.

But none of that will be a substitute for our own interactions and the treatment that follows. We have to accept that the burden of preventing suicides falls on all of us. We can’t afford to be squeamish or judgmental; instead, like Summerfield learned in that dramatic moment with his brother, we can afford to save a life.